Provider Demographics
NPI:1114164142
Name:CLARK, NICOLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 NEWBERRY HWY
Mailing Address - Street 2:
Mailing Address - City:SALUDA
Mailing Address - State:SC
Mailing Address - Zip Code:29138-7808
Mailing Address - Country:US
Mailing Address - Phone:864-445-2500
Mailing Address - Fax:864-445-3956
Practice Address - Street 1:595 NEWBERRY HWY
Practice Address - Street 2:
Practice Address - City:SALUDA
Practice Address - State:SC
Practice Address - Zip Code:29138-7808
Practice Address - Country:US
Practice Address - Phone:864-445-2500
Practice Address - Fax:864-445-3956
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1932PAMedicaid
SC1932PAMedicaid